The biggest killers of under-fives in Katine: poor water and sanitation

Infant and child mortality is a major issue across the developing world – and Uganda is no exception. In the first of three features examining the major threats facing under-fives in Katine, Guardian health editor Sarah Boseley reveals how poor water and sanitation, now being tackled by Amref, has led to disease and infant and child mortality in the region

A polluted well which has worms in the water at the village of Abia next to Emuru swamp in Katine. Photograph: Dan Chung Dan Chung/guardian.co.uk

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Children are lucky to live to their fifth birthday in the developing world. Malnutrition and disease, inextricably linked, kill an estimated 9.7 million under-fives every year, according to Unicef, the UN children's emergency fund. Yet most of these deaths are completely preventable. Relatively simple interventions, such as the provision of clean water and basic immunisation, can save lives.

The under-5 child mortality rate in Uganda was 160 per 1,000 in 1990. By 2002, it had improved to 141 per 1,000. But Uganda, like most of sub-Saharan Africa, is not on course to meet Millennium Development Goal 4 – the commitment to cut child deaths by two-thirds by 2015.

Amref in Katine is attempting to make a difference. The most pressing concern of women in rural Katine, before the start of the project, was the polluted state of their water supply. Women would waylay visiting journalists and gently insist they visit their well or borehole. Time and again, it proved a lamentable sight, infested with worms, overrun by marsh water, cloudy and even, in one case, with faeces floating on the surface.

In the best of all possible worlds, all such water would be boiled before any usage and especially before cooking, drinking or washing hands. In reality, children were drinking from it at source and families had insufficient firewood to boil out all the germs. As a result, waterborne diseases were common, and they are killers. Half the under-five deaths in poor countries are the result of malnutrition and the absence of safe water and sanitation.

Amref's baseline survey in Katine showed that 38% of children under five had suffered diarrhoea in the fortnight prior to the parents being questioned. The highest rates were among the under-twos.

Photograph: Dan Chung Dan Chung/guardian.co.uk

It's a minor inconvenience to most people in developed countries, who may never experience it unless they go traveling, but diarrhoea is one of the biggest killers of small children, because it dehydrates them. It also sets up a vicious circle, causing malnourishment which in turn makes the baby more prone to diarrhoea, and also more susceptible to infections such as malaria and measles.

Unsafe water also regularly causes worm infestations and skin infections. If there is flooding, to which Katine, surrounded by marshlands, is prone, there can be outbreaks of cholera, typhoid and dysentery.

So the most pressing concern of Katine's villagers and the first priority for Amref was to improve the water quality in the villages. So far, eight new boreholes have been drilled and five boreholes rehabilitated.

Has it made a difference yet? Dr Susan Wandera, Amref's deputy country director in Uganda, says they have only anecdotal evidence at present. "The community says diarrhoeal diseases have gone down, particularly in very young children," she said. "It has not been quantified yet. We're waiting for information from the health unit."

It is too early to say whether the health centres are seeing fewer cases, but there is little doubt that they will – nobody denies the clear causal link between polluted water and disease. What may take more time is reducing the toll of disease caused by poor hygiene and sanitation.

This part is hard because it involves behavioural change. But Amref has had substantial experience in this area. It is targeting schools with the aim of changing the hygiene habits of children – who will then spread the word and practice at home. So teachers now give lessons on using latrines rather than heading for the bush, and washing hands afterwards, and again before preparing or eating food. Amref says 41 teachers have now been trained as facilitators.

Not every parent in the UK would take kindly to being told to change their behaviour by their children. Dr Wandera says it works in Uganda because what the children do is backed up by what community leaders say.

"We educate the children but also the community through instructors," she said. "We use the community leaders. They encourage the parents to listen to their children and support them as they try to implement proper hygiene and sanitation activities in the home."

The message is also spread among the adults by the 272 volunteers who are members of the village health teams – five or six from each village.